About 16% of all colorectal surgical patients on Medicare are readmitted to the hospital within 30 days. These readmissions last more than 1 week, on average, and cost the healthcare system $300 million each year. Unfortunately, the warnings of deteriorating condition that are given to patients at discharge after such surgeries are highly subjective. Discharge instructions are often generic, based on conventional wisdom, and lack systematic implementation. Ask the Experts My colleagues and I had a study published in the Journal of the American College of Surgeons that aimed to develop a consensus on warning indicators and recommended action plans for patients after colorectal surgery. For our analysis, 11 nationally recognized experts in colorectal surgery engaged in five rounds of intense deliberation about warning signs that were most important to notice when patients were home after surgery and what should be done when specific complications occurred. We employed the Delphi method, a structured communication technique that uses iterative question-feedback-discussion rounds, to guide the expert panel’s deliberation and reach a consensus. Consensus was defined as having at least 70% of the experts “agreeing” or “strongly agreeing” on a particular point. A consensus was reached on several symptoms that should prompt patients to contact their surgeons: • Wound drainage, opening, or redness. • No bowel movement or lack of gas or stools from an ostomy for more than 24 hours. • Increasing abdominal pain. • Vomiting. • Abdominal swelling. • High ostomy output and/or dark urine or no urine. • Fever greater than 101.5 F°. • Not being able to take anything by mouth for more than 24 hours. Symptoms...

Throughout the United States, readmission rates are increasingly being used for benchmarking across hospitals. Some hospital readmissions may be avoidable, which in turn has led to the levying of financial penalties on hospitals with high risk-adjusted rates. Recent studies have estimated that the 30-day readmission rate for Medicare beneficiaries is almost 20%, and these occurrences cost the U.S. healthcare system as much as $17 billion annually. Several prediction scores have been developed, but few accurately and efficiently predict 30-day readmission risk in general medical patients, explains Jacques Donzé, MD, MSc. “The models that are currently available often do not distinguish between avoidable and unavoidable readmissions, have poor discriminatory power, or use complex scores that aren’t calculable before hospital discharge. Interventions to reduce readmissions are often expensive to implement. To improve efficiency, the highest intensity interventions should be targeted to patients who are most likely to benefit.” A New Prediction Model for 30-Day Readmission In JAMA Internal Medicine, Dr. Donzé and colleagues had a study published that derived and validated a prediction model for potentially avoidable 30-day hospital readmissions in medical patients. The model used administrative and clinical data that was readily available prior to discharge. “Our purpose was to help clinicians target transitional care interventions most efficiently,” Dr. Donzé says. “The goal was to develop a score to predict potentially avoidable readmissions. In other words, we wanted to predict which patients may be most likely to benefit from intensive interventions.” The HOSPITAL score is able to indicate readmission risk before a patient is discharged. This allows clinicians to target a timely transitional care intervention. In their retrospective analysis, Dr....

Recent studies suggest that as many as 2% of discharges from acute care hospitals and EDs in the United States are done against medical advice (AMA). For disadvantaged inner-city facilities, this figure can jump to 6%. “Patients who leave AMA have higher readmission rates,” says Darren P. Mareiniss, MD, JD. “They’re also at greater risk for adverse health effects.” The risk of emergent hospitalization appears highest in the first several days after an AMA discharge. Considering the prevalence and ramifications these discharges can have, Dr. Mareiniss says that “emergency physicians must make every attempt to prevent patients from leaving AMA.” [polldaddy poll=7234675] In the Journal of Emergency Medicine, Dr. Mareiniss and colleagues and the Johns Hopkins Center for Medicine & Law at the Department of Emergency Medicine recently published an article that reviewed legal requirements of the AMA process and examined how properly executed AMA discharges can protect institutions. “In situations when AMA discharge is unavoidable, the key is to optimize legal protection,” Dr. Mareiniss says. Capacity & Disclosing Risks When patients sign out AMA, they must first be deemed as having decision-making capacity. “The assessment of decision-making capacity focuses on a patient’s ability to understand and communicate rational decisions,” explains Dr. Mareiniss. “They need to be able to express their choices and demonstrate an understanding of relevant information. They must also appreciate the significance of this information and its consequences.” Usually, determining capacity is relatively straightforward. However, if capacity is unclear and patients wish to leave AMA, emergency physicians should consult psychiatry whenever feasible. Prolonged observation may be necessary in some situations. In cases of intoxication, mental capacity...

The costs associated with hospital readmission within 30 days of discharge are high. CMS and other payers are now measuring readmission rates and penalizing hospitals financially for poor performance. As a result, reducing readmissions has become a high priority in hospitals throughout the United States. In August 2012, my colleagues and I released a white paper on the current status of work to reduce readmissions and assess the problem in the larger context of accountable care. Promising Approaches to Hospital Discharge Thanks to a decade of experience in leading hospitals and considerable research, the important elements of discharge planning and post-discharge care and support have been identified (Table). But there are many ways to accomplish each element. No “magic bullet” set of interventions exists for every patient because individual risk factors do not triage patients for specific interventions, many possible care breakdowns can also contribute, and some factors are outside the control of the hospital. Most hospitals routinely discharge all patients with an appointment for follow-up care and provide telephone outreach within a day or two to answer questions and check on status. The intensity of additional services and outreach is gauged to patient- and situation-specific risks to recovery and a smooth transition to the next provider of care. Health Information Technology Three key processes highly reliant on health information technology (HIT) are 1) medication reconciliation, 2) communication of patient status and discharge plans of care to receiving providers, and 3) tracking patients after discharge to ensure that care and support is received. HIT is necessary to record and communicate information and close potential loose ends. With greater adoption...

I recently wrote about my plan to reduce hospital readmissions. Now I will discuss the problem of reducing length of stay. The recent hurricane in New York City and the closures of some hospitals requiring the transfer of a large number of patients reminded me of something that happened on 9/11/2001. I was working at a hospital near New York. You may recall that among the many problems that day was a breakdown in communications. Reliable information on the number of casualties and extent of injuries was hard to determine. Late on the morning of 9/11, a meeting was held at my hospital. We canceled all elective surgery and decided to discharge as many patients as possible in preparation for the injured who, sadly, never arrived. Victims either got out of the World Trade Center and walked away or perished. Injured patients were few and were cared for by hospitals in New York. Unaware of what was really happening in the city, we made rounds on every patient and discharged nearly 50 who otherwise would have stayed a day or two longer. As far as I know, there were no complications related to what seemed to be a premature departure from the hospital for many. The next day someone wondered why, if we were able to discharge so many patients on the day of a disaster, could we not do so more often? Granted, once a wholesale cleanout took place, there would probably not be 50 patients eligible for discharge every day. But it might be 10 or 15. Multiply that by a few thousand hospitals and you might...